How get an Advantage from Minimally Invasive Nucleoplasty Surgery

Minimally invasive spinal surgery of traditional open surgery to relieve chronic back pain is ideal for outpatient facilities. These disc decompression cases are usually short procedures, with handpicked, low-risk patients, strong success ratios and fewer post-op complications than open surgery. And the demand for these procedures continues to surge. But how do you make disk decompression surgery profitable? I've been performing outpatient spinal surgery for 15 years. 

Not all herniated disk patients are eligible for minimally invasive spinal surgery. The ideal candidate has:

·         No severe spinal stenosis (build-up of bone in the spinal cavity).

·         Well-maintained disc height, preferably with 30 percent or less disc collapse.

If such conservative treatments as bed rest, analgesics and physical therapy fail to relieve the problem, I do tests such as discography, MRI and CAT scans. If these tests confirm that the problem is a herniated disc and the patient meets the aforementioned criteria, he is a good candidate for outpatient surgery such as nucleoplasty. 

If you want to make a case with your payers to reimburse for spinal procedures, you can draw on the significant volume of clinical data proving the efficacy of outpatient disc surgery, which strongly suggests that these procedures can prevent the need for more expensive open procedures. Open disc surgery results in epidural scarring and also requires a much lengthier recovery period than minimally invasive spinal surgery, where the patient can be ambulatory the same day and post-op pain is minimal. 

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Nucleoplasty is not appropriate for large herniations or those with extruded fragments; when surgery is required lumbar microdiscectomy or discectomy remain the preferred treatment in these cases. The majority of herniations, however, are small and contained. In over 50% of cases, clinical symptoms disappear with time, and the herniation shrinks over 8-9 months. Nucleoplasty can provide pain relief during this period. 

If the disc prolapse is mainly central (that is, directed backwards rather than to one or other side, the presenting complaint is likely to be back pain rather than leg pain. Clinical features that indicate a greater likelihood of nucleoplasty working in such instances include severe restriction of lumbar flexion (bending forwards) and reduced straight leg raising test. These tests indicate the possibility of dural irritation. The disc prolapse should be more than minor. 

If the disc prolapse directed backwards but more to one side (i.e. posterolateral) it is more likely that leg pain will be a feature. This pain may be referred in nature rather than radicular. That is, the leg pain may be diffuse rather than shooting. 

Nucleoplasty may be an appropriate treatment for patients with:

·         Radicular pain greater than back pain

·         Poor response to previous medical treatment and physiotherapy

·         MRI demonstrating disc herniation less than 6mm in size.

The procedure may not be appropriate for patients with:

• ·         Spondylolisthesis
• ·         Segmental instability
• ·         Herniation  ≥6mm in size, or with extruded fragments
• ·         Severe disc degeneration
• ·         MRI finding of complete annular disruption
• ·         Age >60 years
• ·         A painful disc which has height less than 50% of that of the adjacent disc.

Some practitioners also perform discography prior to treatment. In some cases, this is intended to confirm concordant pain at each level, and rule out the involvement of other levels. In other cases, the procedure is conducted to confirm that the outer annulus has retained its integrity, and to identify patients with true internal disc disruption.

Efficacy

A systematic review of the efficacy of the nucleoplasty procedure for treating LBP from symptomatic, contained disc herniation found Level II-3 (reasonably strong) evidence for improvement in pain or function after a nucleoplasty procedure.

No randomised control trials investigating nucleoplasty have been published. A range of lower quality studies have assessed the efficacy of the treatment, with a majority reporting positive or “promising” results. Recently published practice guidelines for the evidence-based treatment of chronic spinal pain have concluded that there is limited evidence for the effectiveness of nucleoplasty.

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